1. (a) All beneficiaries requesting an exemption shall complete and submit BFA Form 330 “Exemption Request Form Granite Advantage Health Care Program” (06/19).

2. (b) Beneficiaries requiring certification by a licensed medical professional in (c) below shall have a licensed medical professional certify on BFA Form 330 to the following:

   “As a licensed medical professional caring for this beneficiary, I hereby certify (based on the description of the exemptions provided in the instructions to this form) that the beneficiary meets the qualifications for the exemption(s) requested in Section II.”

3. (c) Beneficiaries shall provide the following third party certification or documentation to the department for the indicated exemption types:

   1. (1) For beneficiaries unable to participate due to illness, incapacity, or treatment under He-W 837.03(a)(1) above, provide a certification by a licensed medical professional specifying the duration and limitations of the illness, incapacity, or treatment. The duration of the exemption shall be one month or the date range specified by the licensed medical professional, whichever is longer;
   2. (2) For beneficiaries participating in a state certified drug court program under He-W 837.03(a)(2) above, provide a copy of the legal documentation requiring the beneficiary to participate in the drug court program. The duration of this exemption shall be one year from the date that the required documentation is received;
   3. (3) For a parent or caretaker under He-W 837.03(a)(3) above, provide a certification by a licensed medical professional that specifies the duration that such care is required. Unless specified otherwise by the licensed medical professional, the duration of this exemption shall be one year from the date that the required documentation is received;
   4. (4) For a parent or caretaker of a dependent child under 6 years of age under He-W 837.03(a)(4) above, provide a self-attestation and the child’s date of birth;
   5. (5) For a custodial parent or caretaker of a child with developmental disabilities under He-W 837.03(a)(5) above, provide a certification by a licensed medical professional of the child’s developmental disability. The duration of this exemption shall be for as long as the particular circumstance continues to exist;
   6. (6) For beneficiaries with a disability under He-W 837.03(a)(7) above, provide an annual certification by a licensed medical professional of the beneficiary’s inability to meet the community engagement requirement for reasons related to the disability. The duration of this exemption shall be one year from the date that the required documentation is received or the date range specified by the licensed medical professional, whichever is less;
   7. (7) For beneficiaries residing with an immediate family member with a disability under He-W 837.03(a)(8) above, provide an annual attestation of the beneficiary’s inability to meet the community engagement requirement for reasons related to the family member’s disability and an annual certification by the family member’s licensed medical professional specifying the family member’s disability. The duration of this exemption shall be one year from the date that the required documentation is received or the date range specified by the licensed medical professional, whichever is less;
   8. (8) For beneficiaries unable to participate due to hospitalization or serious illness under He-W 837.03(a)(9) above, provide copies of discharge summaries, or financial or billing information, documenting the hospitalization or serious illness or dates of stay. The duration of this exemption shall be one month or the date range specified by the licensed medical professional, whichever is longer;
   9. (9) For beneficiaries who are unable to participate due to hospitalization or serious illness of an immediate family member under He-W 837.03(a)(10) above, provide copies of the family member’s discharge summaries, or financial or billing information, documenting the hospitalization or serious illness. The duration of this exemption shall be one month or the date range specified by the licensed medical professional, whichever is longer; and

   10. (10) For medically frail beneficiaries under He-W 837.03(a)(11) above, an annual completion and submission of a. and b. below:

       1. a. BFA Form 320A “Beneficiary Authorization for Licensed Medical Professional to Release Protected Health Information - Granite Advantage Health Care Program” (05/19) permitting and authorizing disclosure of protection health information as follows:

          “I hereby authorize the following licensed medical professional to disclose my protected health information for the purposes described above.”

          “In addition, I hereby authorize the following specific disclosures (place your initials on the line by those statements which apply)

          I specifically authorize the release of my mental health treatment records.

          I specifically authorize the release of my HIV and AIDS results and/or treatment.

          I specifically authorize the release of my alcohol and/or drug abuse treatment records in accordance with 42 CFR Part 2.”

          “I give authorization for my protected health information to be released to the following individual or organization:

          Name: Granite Advantage Health Care Program Manager

          Organization: Department of Health and Human Services

          Address: DHHS, Granite Advantage Health Care Program, P.O. Box 3778, Concord, NH 03302-3778 or Fax # 603-271-5623

          I understand this authorization may be revoked by notifying the Department of Health and Human Services in writing to the address above”; and

       2. b. BFA Form 331 “Licensed Medical Professional Certification of Medical Frailty Granite Advantage Health Care Program” (05/19) indicating that the beneficiary is unable to comply with the work and community engagement requirement as a result of their condition including the duration of such disability. The duration of this exemption shall be one year from the date that the required certification is received or the date range specified by the licensed medical professional, whichever is less. The licensed medical professional shall certify as follows:

          “As a licensed medical professional caring for this beneficiary, I hereby certify that the beneficiary is medically frail based on the beneficiary having one or more of the conditions identified above.”

4. (d) To the extent practicable, third party certification or documentation shall be submitted to the department with the form required in (a) above.
5. (e) A request for an exemption under this section shall not be considered complete until all of the required documentation is received by the department.
6. (f) For pregnant women, the beneficiary may report pregnancy by completing and submitting BFA Form 330 or by informing the department.

Source. #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.05); BFA form 330 in (a) amd by #12828